Why rejected claims need a workflow, not a note

Section 01

Common rejected claim patterns

A handful of reject reasons drive most of the volume in community and high-volume pharmacies.

• Product not covered (Reject 70) — alternate NDC or PA needed.
• Refill too soon (Reject 79) — schedule into the fill window.
• Prior auth required (Reject 75) — open a PA case.
• Missing or invalid info (Reject 7x family) — re-bill with correct data.

Section 02

How claim issues get lost

Rejections that live as a paper slip or a queued message tend to fall through hand-offs.

• Slip sits in a tray until someone notices.
• Tech who knows the fix isn't on shift.
• Patient calls before anyone takes the next step.

Section 03

What to track

A claim case needs more than the reject code to be useful tomorrow.

• Reject code and payer.
• Patient and prescription reference.
• Suggested next action (alt NDC, PA, re-bill, prescriber outreach).
• Owner and current status.
• Last action timestamp and outcome.

Section 04

Owner, status, next action

Every case answers three questions at a glance: who owns it, what status it is in, and what happens next. If a row can't answer all three, the workflow needs to be tightened.

Section 05

Patient update timing

Patients tolerate delay; they don't tolerate silence. Send an update when the claim case opens with a blocker, and again when it resolves.

Section 06

Refillops workflow example